The View from the Vue (4 page)

Mr. Washington stood up and extended his hand, which I gripped. “Thank you very much, Dr. Karp,” he said. “I do trust that you will attempt to effect my prompt release from this unjustified confinement.”

I assured him emphatically that I was firmly in his corner, proceeded directly to the chart rack, pulled out his chart, and read the police report from the cops who had brought him in. It said that he had been drunk and abusive, but made no mention of his set-to-with the gang of white youths. I ground my teeth loudly. Did they have to add falsification by omission to injustice?

Leaving a cloud of smoke to mark my spot, I sought out Dr. Rothstein and poured out the story in a torrent. Dr. Rothstein stood there quietly throughout my performance. When I finished, he asked, “What did the admitting resident have to say about him?”

I gulped. My righteous indignation had prevented me from looking past the police report. Together we went back to the chart rack and read the resident’s write-up. It was concise and to the point. It said that Mr. Washington had reeked of the demon rum and that he hadn’t been making much sense when he spoke. The resident’s diagnosis was: acute alcoholic psychosis.

“That psych Admitting Office is a snakepit,” I said hastily. “Maybe the resident read the police report but didn’t have enough time to actually spend talking to Mr. Washington.”

“That’s possible,” Dr. Rothstein said. “But I don’t think it’s very likely.”

Neither did the rational part of my mind, but that entity had already been submerged in my emotions.
“You
come and talk to him,” I urged. “You’ll see he’s no more crazy than we are.”

Dr. Rothstein smiled and followed me to Mr. Washington. He listened as the patient told his story again, and then we walked away together.

“Well?” I asked as we moved out of earshot.

“I think he ought to stay for observation for another day or two,” said Dr. Rothstein. He held up his hand to stop my howl of protest before it could start. “Tell you what,” he continued. “I’d like you to check up on him periodically during the day. Then tonight, before you go home, leave your phone number and tell them to call you if there’s any…change in his condition. Okay? Just be a little patient; I think you may learn something from this case.”

Mr. Washington appeared to be fine all day, but when I stopped to say good-night to him, he seemed agitated. His hands shook as he tried to eat his dinner, and he couldn’t seem to sit still in his chair. I asked what was wrong.

“If you were confined in a place like this,” said Mr. Washington, in a bass whine, “I assure you, you’d feel nervous too.”

I tried to reassure him, and told him to hold out till morning, at which time I’d again attempt to have him released.

At a quarter to one in the morning, my phone rang. The ward clerk told me to come right over, that Mr. Washington’s condition had definitely changed.

My first reaction upon arriving at the ward was mixed disbelief and anger. Mr. Washington was strapped into a restraint bed, and he was struggling so fiercely that the whole apparatus was bouncing about on the floor. He was screaming unintelligible words and sentence fragments, and his finely measured speech had vanished. His vocabulary and dialect had become pure Bowery.

I leaned over him. “Mr. Washington, Mr. Washington,” I shouted. “What’s the matter? What have they done to you?”

His eyes rolled uncontrollably. “Oooooh, no!” he wailed. “No, no, no, no, no! Ge’em oudda here, ge’em away.” He brushed clumsily at the air in front of his face. Streams of sweat rolled off his forehead in every direction.

A nurse walked up beside me. “First time you see a good case of the DT’s?” she asked. “That’s the delirium tremens, when they sees things an’ hears things an’ shakes all over.” She shook her head and chuckled. “I just dunno. These ol’ alkies, long as they keep drinkin’ they’re okay, but then they come in here an’ go a day without no booze, they all get the DT’s.” She jabbed a needle into Mr. Washington’s rump, emptied the syringeful of tranquilizer, and crooned, “Doncha worry now, honey, this’s gonna make all them snakes ‘n’ elephants go ’way, hear?”

My ears began to burn. I could have killed Mr. Washington for hoodwinking me, and I would not have suffered a pang of remorse. Nor were my feelings mitigated the next morning when Dr. Rothstein asked me to tell the group about my patient, and then, with an arch smile, he asked me whether I had learned anything from the case.

Bellevue abounded in contrasts. Two years later, as an intern on the psychomedicine ward, I took care of Mr. Washington’s opposite number. His name was Harold Bullock, and he even looked like Mr. Washington. Bullock was brought in one evening as a florid DTer, screaming and hallucinating, having been picked up on a midtown street. He was uncontrollable on admission, and it took four of us to get him into restraints. Only when we had sedated him was I able to examine him. I could find nothing of significance aside from his disorientation and a fever of 101°. There was no infectious explanation for the latter, and so I chalked it up to the joint effect of alcohol and agitation, and proceeded to treat him for his DT’s.

On rounds the next day, Mr. Bullock was no better, but that wasn’t unusual: attacks of DT’s can last for days. However, his temperature was now 102.6°, and our resident, Dr. Ronnie Edelson, frowned as he took note of that. “Where’s the fever coming from?” he asked me sharply.

I shrugged. “I guess it’s just the DT’s,” I answered. “His chest is clear; there’s no urinary tract infection; no abscesses on him; liver’s not enlarged. It must be a metabolic fever.”

Ronnie looked back at Mr. Bullock, and pulled thoughtfully at his chin. Then he leaned over, put his hand under the patient’s head, and lifted. Mr. Bullock’s entire body rose off the bed.

I noticed a very unpleasant sinking sensation in the pit of my stomach.

“
Schmuck
!” said Ronnie, in a withering tone. “This guy’s neck is as rigid as a board. He’s got meningitis. Plenty of alkies do, y’know. Get a hold of an LP tray and do a spinal tap, fast.”

Less than ten minutes later I had a needle in Mr. Bullock’s back. I expected to see pure pus come out of it, but when I removed the stylet, to my amazement, out flowed crystal-clear fluid. I collected a sample of it, took it to the lab, and analyzed it. Then I went looking for Ronnie.

“I don’t know why he’s so stiff,” I said, “but one thing he
hasn’t
got is meningitis. His fluid’s perfectly benign. No bacteria in it, no pus cells—”

“Was it under increased pressure?”

“High normal. But not elevated.”

Ronnie shook his head. “With a neck like that he’s got to have meningitis,” he said. “Did you send a sample for culture?”

“I asked them to check for every bacterium I could think of.”

“Did you ask for fungal cultures too?”

“Fungi?” I wrinkled my forehead. “That’s reaching pretty far out, isn’t it?”

“Did you?”

“No, I didn’t. I really didn’t think…”

“No, that’s right. You didn’t think,” said Ronnie, thoroughly exasperated. “I’ll only forgive you because it’s early in the internship year. Listen. One thing you’ve got to learn is that Bellevue is a far-out place, and you’ve got to think of far-out diseases here. When you work at a nice, respectable hospital like Beth Israel, and you hear hoofbeats, you can pretty much count on seeing horses. But at The Vue, it’s more likely to be zebras—or even unicorns. So you go back and tell the lab to do fungal cultures on that spinal fluid. Get an India ink prep too.”

“What the hell’s an India ink prep?” I asked.

“It’s for a fungus called cryptococcus,” said Ronnie. “You can read about it; it’s spread by airborne dissemination of particles of bird shit. You mix India ink on a slide with the spinal fluid, and the ink stains the cryptococcus so it shows up under the microscope.”

I snickered, and then took a look at Ronnie’s face. “All right, all right,” I mumbled. “I’ll get it all. Maybe he raises pigeons or something.”

Ronnie grinned.
“Now
you’re starting to think,” he said. “And while we’re waiting for the results, you’d better start him off on penicillin and a broad-spectrum antibiotic. That’ll cover most of the bacteria, and we’ll keep after the lab for a quick culture result.”

I did what Ronnie wanted, and then spent the rest of the day chasing one problem after another. About five o’clock, I was sitting at the charting desk drinking a bottle of soda when the phone rang. The clerk answered it and then waved the receiver in my direction. “Lab callin’, Dr. Karp,” she said.

I took the phone and said hello. The voice at the other end asked whether I was Dr. Karp; I assured it I was.

“You ordered an India ink prep on a patient Bullock?”

“Yep. What about it?”

“What’s about it is that it’s positive! Damn slide was crawling with cryptococcus! Dr. McKenzie here in the lab says he’s never seen so many bugs on a slide.”

I whispered a thank-you, hung up the phone, and penitently went looking for Ronnie Edelson. He looked annoyed as I gave him the report. “That’s not something you ought to be joking about,” he said. “What if I took you seriously?”

“You’d better take me seriously,” I answered. “That stupid India ink prep was as positive as it could be. I’m not kidding.”

“You’re kidding,” said Ronnie. He looked closely at me. “No, I don’t think you are,” he said slowly. Then he started to laugh.

“Now do you believe in unicorns?” he asked.

We treated our unicorn with intravenous infusions of amphotericin B, the only antibiotic effective against cryptococcus, and a drug so toxic that it can cause livers and kidneys to rot. Every time I infused it, it produced such a severe reaction in the vein that the blood vessel was thereafter useless. Since it took two months to cure Mr. Bullock, I wiped out virtually every vein on his body except the one running on top of his penis. A couple of times near the end of his treatment, even that one was in danger.

Far from being an alcoholic, Mr. Bullock turned out to be a very solid citizen who had been employed in a midtown office. On investigation, we learned that his desk had been located right next to the air conditioner, and that a flock of pigeons had been in the habit of dropping their loads on the outside window ledge. The air conditioner, subsequently, had blown in a pure culture of cryptococcus for Mr. Bullock to inhale. He had been complaining of headaches, nausea, and dizziness for a few days before the cops found him on the street.

When he regained his right mind, we offered to transfer him to the general medical service, out of the psych building, but he refused. “You knew what was wrong with me,” he said, “and I figure you saved my life. I don’t want anyone else treating me.” So Mr. Bullock cheerfully spent two months locked in the psychomedicine ward. He was not in the least unhappy about having been railroaded.

The multiple problems we encountered in trying to treat psychotic patients with medical illnesses are illustrated in the case of Mr. James St. Peter. James was admitted to the psychomedicine ward one night during the first week of my internship. He was suffering from pneumonia, and had been sent to psych because of his obvious dementia. I couldn’t be certain whether he was retarded, schizophrenic, or both. Some people are doubly blessed. In any case, all he did was babble incoherently at people or objects that he either was hallucinating or pretending to see. He was an emaciated, eighty-pound, totally bald, black man. As he lay in his bed behind the safety rails, he demonstrated terrible anxiety and apprehension. His eyes almost popped out of his head as he continually looked about, glancing here and there, and addressing questions and answers to invisible companions. Now and then he managed to answer a question that I put to him before he floated away again into the other world.

We treated his pneumonia with antibiotics, and although his condition improved, even when his fever broke he was no less delirious. He had been in the hospital for a couple of days when a faculty psychiatrist came by to make rounds with us. When he reached James’s bed, he asked the little man several questions, but James was too busy conversing with the spirit world to pay the shrink any mind. Finally, the psychiatrist leaned over the bed rail and, nose to nose with the patient, boomed out, “James, now tell me: Did you ever do anything bad—like robbing a liquor store?”

The little fellow came back to what we call reality. He looked up in panic at the psychiatrist, his eyes protruding far in front of his face, and stammered, “N-n-n-no-suh. Hain’t nevuh did dat. B-b-b-but—St. Peter James—St. Peter James—he done it.” Then he went back to play with his friends.

The psychiatrist looked at the name at the foot of the bed. It read, James St. Peter, the same as on the admission slip. “Aha,” exclaimed our Freud image. “That’s classic.” He smiled smugly.

We all looked at each other, and finally the resident decided to swallow his pride in the interest of knowledge. “Classic for what, sir?” he asked.

“Why, for schizophrenia! That’s what they always do. Not only do they assume another personality, but they give the other personality the inverted form of their own name. That way, it symbolizes that the assumed personality—who they usually perceive as evil—is the opposite of what they are themselves.” He smiled magnanimously at the group. All of us swine nodded and tucked the pearl away for future use.

The psychiatrist was so enthusiastic that over the next couple of days he brought several groups to our ward to see the classic patient. Psychiatric colleagues, residents, and medical students all got to hear, “St. Peter James—St. Peter James—he done it.”

James’s pneumonia was responding so well that we were already thinking about which nursing home we could send him to when, one afternoon, the nurse called to tell us that James St. Peter’s blood pressure was unobtainable. We found him cold and clammy; a physical examination and an X-ray showed us that a lung abscess, previously hidden by the pneumonia, had ruptured and sent the patient into shock. This bacterial shock, even now a terribly serious problem, was at that time, for all practical purposes, a death sentence. But we tried. We pumped into James every medication we thought might have a chance of helping him, but he continued to deteriorate. So, I decided we’d better call the next of kin. I asked the nurse whether any such were listed for the patient. She checked the chart and hollered back, “Yeah, Dr. Karp, he’s got a brother, William.”